Fever in a kid is one of those roll-your-eyes-what-the-hell-is-wrong-with-them things, but fever plus a headache leads you, scarily, down the path to meningitis. You do not want to miss meningitis, because it moves fast and kills often.

The problem with meningitis is that the test for it is a spinal tap, which carries its own share of complications. Plus… it’s a big fucking needle in your spine. Kids† don’t respond well with big needles in their spines.

So, carefully, I examined her, trying to rule out meningitis as a diagnosis. No neck stiffness, which was a good thing. Brother had the sniffles at home, which was a strike against. I noticed a small red dot on her hand that looked like a bug bite, but nothing else jumped out.

As a resident, you ALWAYS have an attending physician - someone boarded in your specialty who has finished residency - watching over you. So, I told my attending the story, and she nodded, “I agree, from that story we can’t rule out meningitis. I’ll go take a look at her.”

A few minutes later she came back to the doctor charting room, a huge smile on her face.

“You don’t have to ‘tap her,” she grinned, “she’s got a subtle finding you may have missed. Did you get a good look at the back of her throat?”

In fact, I hadn’t. I’m still hesitant to do things patients don’t enjoy: sticking tongue depressors in kids’ mouths, doing pelvic exams on skittish women, performing rectal exams on healthy young trauma victims.

So, with her supervision, I went back in and really pulled the girl’s tongue out of the way. Sure enough, that same little red bump I had overlooked on her hand was in the back of her throat. Pulling off her shoes and socks revealed one of them on each foot.

Hand, foot, and mouth disease. Classic presentation. Common symptoms include fever, headache, and rash. Treatment is simply ibuprofen for her fever and water for dehydration.

Attending physician, you rock.

† (also, adults)

The patient’s chief complaint was “vaginal discharge x 2 weeks”, which - at minimum - requires a pelvic exam. Dr. O interviewed the patient, getting some more background information. Whitish discharge. Unprotected sex. New boyfriend. Run of the mill, most likely a sexually transmitted infection. The nurse comes in, they set up for the pelvic, and begin.

By her account, this was the most horrifically awful pelvic examination she has ever performed. Milky white fluid was leaking everywhere. On the sheets, on her scrubs, on the speculum. It was all she could take not to gag.

Impeccable, composed physician that she is, Dr. O obtained her samples, and then calmly told the patient that she was quite concerned about the amount of discharge. “This,” she said, “is honestly the most fluid I have ever seen on a pelvic exam. We will empirically treat you with antibiotics for a suspected STI, and will call you with the results of the tests as soon as we have them.”

The patient looked at her and said “Aw, that ain’t no discharge. Me and my boyfriend just raw-dogged it right before we came to the ER. That’s all cum.”

He was 17, high, and hard to talk to. Eyes darting around the room as if the cupboard in the corner was out to get him. Sunken back in his oversized shirt, with his crisp new hat pulled low over his face, engrossed in the TV. Mom, clearly concerned, started the conversation before I could even open my mouth.

“Doc, he is acting WIERD lately.”

That will happen, I thought to myself, when your kid starts smoking lots of pot.

But I soldiered on, trying to avoid judging prematurely. It was a perfect case for a mother bringing in her drug-addled child. The interview was difficult, because he had an extremely flat affect - a medical term for not showing any emotion - and simply didn’t seem to trust me. He was, however, incredibly straighforward about his drug use. Marijuana every 3-4 days, because it made him feel safer.

Safer?

There is a lot said in medicine about a sixth sense; that feeling that something simply isn’t right. People smoke weed for a lot of different reasons, but when they do it because it calms something inside of them, you start to wonder.

Rather than simply chalking his behavior up to drug use, I questioned him further. It was futile at first, but as I kept at it in my doctor persona, he slowly opened up. Suddenly he started talking about Michael Jackson’s death… and how it was “really telling him things” and how “nobody seemed to understand it” but him. CNN was was sending him messages through the TV screen.

He continued, painting me a picture of persecution and fear. He had been followed to the corner store the other day, and he knew they were spying on him through the adjacent aisles. He could overhear wisps of their conversations about him. This had been happening for years, but nobody ever listened. The weed made him feel safe, if only temporarily.

The nail in the coffin was that his biological grandmother and mother both had severe schizophrenia - a fact that somehow was missed each of the 3 times in the past month he was admitted to the Emergency Department for “bizarre behavior”. Previous notes documented “substance abuse” and not much more.

After reviewing his records, I went back into the room and discussed my concern that he was manifesting signs of paranoid schizophrenia. I had made an appointment for him with Behavioral Health, and he was to go there straight from the ER.

The mom simply thanked me, a look of deep sadness in her eyes, and went to sit on the bed with him. He snuggled up to her and dropped his head on her shoulder, eyes glazed over as he watched the news coverage about Michael Jackson’s death. She started crying, quietly, as I left the room.

My first shift is an overnight in the Pediatrics Emergency Department, which is anxiety provoking. I rarely saw pediatric ED cases at my medical school, so it’s pretty foreign to me. On top of which: it’s children. People outside the medical field are scared enough of what it means if their child has a fever. Me? I’m terrified. Because now I’m supposed to know.

I think we don’t give ourselves enough credit when the stakes are high. I’m sure I know more than I think I do - didn’t go to 4 years of medical school for nothing - but the thoughts keep intruding.

What if an unstable asthmatic comes in and I don’t know which drugs to order?

What if a kid comes in, confused and lethargic, and I don’t know if he has meningitis?

What if a 6 year old swallowed a nail?

What if?

The day had gone well so far; all 14 of us rowdy ER folks had been identified right off the bat by the nurses running the course, who laughed, “You all must be the emergency docs. Every year, we can always spot the emergency docs.” Too loud, having far too much fun for an ACLS course, rambunctious. Fun.

The group before us - 2 OB/GYNs and a GP - shamble out of the testing center. They had failed, and had to repeat the simulation. This was happening to a disturbingly large percentage of the groups leaving the sim labs. Not us. We knew our shit. Too cocky.

The three of us were ushered into the room. The scenario: Mr. Jones, a 56 year old male, presents to the Emergency Department for shortness of breath and chest pain. Cookie cutter ED stuff, but we knew that the simulation was set up so he would rapidly decompensate. Advanced lifesaving measures would be required.

A voice overhead, “The simulation is commencing.”

We looked at each other, suddenly nervous from the utter unfamiliarity of the testing center, a perfectly simulated hospital room down to the sheets on the bed. We hadn’t been tested here before. The realization sinks in that none of us have ever given orders in our lives.

I fool around for 2 minutes trying to figure out how to get the monitor to display blood pressures and the cardiac rhythm. Without these and a few other critical vital signs, we’ll never know how to proceed.

Dr. A goes to introduce himself to the “patient” - a million-dollar state of the art mannekin - and asks what’s wrong. A groan issues from Mr. Jones. This isn’t good. His pulse is weak and rapid. We crowd around the monitor, tapping buttons and fiddling with wires. Precious time is lost.

We stand, each working haphazardly. The patient is in ventricular tachycardia. Algorithms temporarily forgotten, we debate. Do we shock or give drugs? What’s more critical, heart or lungs? More time is lost. The patient, previously ill, is now dying as fast as he can.

The decision is made to put him on a ventilator. Oxygen levels have been dropping and he is unconscious. Dr. E prepares his equipment and we spend another few minutes trying to find the drugs we need to paralyze the patient prior to the procedure.

The procedure is hard, almost impossible. 8 of our 10 minutes have gone by and we have idly sat by doing nothing. Dr. A and I watch Dr. E sweat through the intubation, offering advice.

The horrible “BEEEEEEEEEEEEEEEEEEP” of flatline issues from the cardiac monitor. We’ve killed Mr. Jones.

“Doctors, you may leave the room,” a disembodied voice informs us, “we will perform remedial testing in 30 minutes.”

We shuffle out of the room, heads hung low. Added to the shame of failing at our chosen specialty was the horrible feeling that we just killed someone. It was just a mannekin, sure, but those 10 minutes felt all too real.

===

We spent our 30 minutes figuring out what went wrong. I think I grew up more in that half hour than I have in the past year. I am not comfortable wearing my doctor shoes but like it or not, I’m wearing them now. Why didn’t anything get done in that simulation? Because we all waited to be told what to do.

Who am I to tell a nurse who has been working 20 years that I want things done my way? I only received my medical diploma in the mail a week ago. And yet, if I don’t tell that nurse what to do… it won’t happen. This is, in fact, the career I have chosen. To give orders, not to follow them. I need to get comfortable with that. And I need to be ok with the fact that I am a doctor.

===

We draw straws. Dr. E is going to lead the code. Dr. A and I will act as his assistants. The code starts. Dr. E methodically works through the algorithm. A-B-C. IV-Oxygen-Monitor. Ventricular tachycardia.

It runs like clockwork, Dr. E truly acting like a doctor. I’m proud of him. I follow my orders, giving advice when he asks what the next step is. The final decision is his.

We lose a pulse, but we know what to do. Dr. E asks me to commence CPR while he fires up the paddles. The simulation is fake but the defibrillator is real - when he calls “CLEAR” we stand back. A shock is delivered. A few more cycles of CPR and suddenly we feel a pulse.

The voice, from overhead, “Congratulations, Doctors. You are now certified in Advanced Cardiac Life Support.”